E2266. Stop the Leak: InterventionalTechniques in Thoracic Duct Embolization
  1. Michael Patel; Mount Sinai Medical Center
  2. Kevin Beker; Mount Sinai Medical Center
  3. Robert Beasley; Mount Sinai Medical Center
  4. Brandon Olivieri; Mount Sinai Medical Center
  5. Adam Zybulewski; Mount Sinai Medical Center
A lymphatic chyle leak into the pleural cavity or peritoneum can evolve into a debilitating condition for selective patients that necessitate recurrent drainage. Patients commonly endure uncomfortable abdominal distention with recurrent peritoneal leak, known as chylous ascites, or shortness of breath with recurrent pleural leak, known as chylothorax. Non-traumatic causes of chyle leak tend to be more difficult to treatment encompass congenital or acquired, malignant, inflammatory, infectious, idiopathic, and post-operative conditions. Gold standard diagnosis is made by fluid analysis with triglyceride content greater than 200 mg/dL. Chylous leaks can be managed medically with dietary changes as well as agents such as octreotide or somatostatin. When refractory, lymphangiogram with thoracic duct embolization may be considered for treatment and diagnosis.

Educational Goals / Teaching Points
Patient quality of life is greatly affected in the setting of recurrent chylous leak as it requires frequent patient visits to coincide with the symptomology in addition to increased risk of infection in the setting of frequent drainage. Chylous effusions and ascites are associated with significant morbidity as there is increased risk of malnourishment and infection due to loss of plasma proteins, lymphocytes, and nutrients from the lymphatic system. The goal of our presentation is to review the clinical features, anatomy, pathophysiology, diagnosis, and management of chylous effusion/ascites with emphasis on interventional techniques using case-based series.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
Here, we present 3 cases of recurrent chylous leak treated with 3 different interventional techniques. First, a 40-year-old female with past medical history (PMH) of Systemic Lupus Erythematosus (SLE) and recurrent right chylothorax was treated with thoracic duct embolization via retrograde catheterization of the terminal thoracic duct at the left jugulovenous angle. This technique was possible as patient presented with a 'simple' type duct anatomy allowing for easy retrograde cannulation. The next case is an 83-year-old male with PMH of lobectomy and mediastinal lymphadenectomy for bronchogenic malignancy presenting with recurring right chylothorax was treated with pelvic lymphangiogram and percutaneous transabdominal thoracic duct glue embolization. Lastly, a 71-year-old male with PMH of pancreatic adenocarcinoma presenting with painful, recurrent chylous ascites was treated with balloon-occluded abdominal lymphangiography and embolization (BORALE) via percutaneous transabdominal access of the cisterna chyli and retrograde left brachial vein access. Distal endolymphatic occlusion of the thoracic duct allows better identification of a leak because of the pressurized lymphatic system.

Interventional radiologists must be familiar with the clinical presentation and diagnosis of a chyle leak as well as the various techniques that can be used for treatment so as to provide definitive treatment and/or increase quality of life of our patients.